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Collects member identification, mailing/contact details, birth date, and required formatting for dates in MM/DD/YYYY. Provides eligibility options for involuntary furlough due to temporary closure or a declared disaster/emergency, or for leave without pay. Requires a $200 nonrefundable actuarial calculation fee and identifies applicable LASERS plans. Includes member authorization, signature/date, and an employer certification section with instructions to submit Form 2-10B for contribution breakdown.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":40,"@type":76,"position":81},"https://docshare.wps.com/document/research-report/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/application-for-purchase-of-leave-lars-11163-instructions-and-certification/181529/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/application-for-purchase-of-leave-lars-11163-instructions-and-certification/181529.png","ImageObject",300,407,{"name":92,"@type":93},"Caleb Sterling","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-18","2026-09-02",true,{"@type":102,"interactionType":103,"userInteractionCount":29},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What is the purpose of this LASERS application for purchase of leave?","Question",{"text":112,"@type":113},"It requests to purchase service and salary credit for qualifying days of furlough or leave without pay under La.R.S. 11:163. The form collects member details and authorizations needed for actuarial calculations.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What eligibility options are available to members?",{"text":117,"@type":113},"Members can choose to purchase credit for days involuntarily furloughed due to temporary closure or a gubernatorially declared disaster/emergency, or for days placed on or voluntarily took leave without pay.",{"name":119,"@type":110,"acceptedAnswer":120},"What fee is required and how can it be paid?",{"text":121,"@type":113},"A nonrefundable $200 fee is required for the actuarial calculation. 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\nApplication for Purchase of Leave(La.R.S.11:163)  \nMember's First NameMiddle NameLast NameToday's DateSocial Security Number  \nIMPORTANT:Complete the entire form.Follow the specific instructions for each section.All dates should be in MM/DD/YYYY format.  \nSECTION1:MEMBER'S INFORMATIONMember's Mailing Address          CityStateZip CodeDaytime Area Code/Phone NumberEvening Area Code/Phone NumberEmail AddressMember's Birth Date  \n# SECTION 2:INSTRUCTIONS\n\nCheck one of the following options:  \nIwish to purchase service and salary credit for each day that Iwas involuntarily furloughed due to the temporary closure of my employeror a gubernatorially declared disaster or emergency.  \n□Iwish to purchase service credit for each day that I was placed on or voluntarily took leave without pay.  \nYou must pay a nonrefundable fee of $200.00 to LASERS for the actuarial calculation.This fee may be paid by personal check,cashier'scheck,certified check,or money order made payable to LASERS and should accompany this application.There will be a $15.00 charge forall checks returned due to insufficient funds.  \nIndicate which LASERS plan applies to you by checking the appropriate box below:  \n□Regular Member,hired prior to July 1,2006  \n□Regular Member,hired between July 1,2006 and December 31,2010  \n□Regular Member,hired between January 1,2011,and June 30,2015  \n□Regular Member,hired on or after July 1,2015  \n□Bridge Police Employee for the Crescent City Connection (DOTD),hired prior to January 1,2011  \nCorrectional Officer,Security Personnel,or Probation &Parole Officer employed by the LADepartment of Public Safety &Corrections,  \n02-10 R012024  \nCONTINUE ON NEXT PAGE  \n□Peace Officer,hired prior to January 1,2011  \n□Alcohol &Tobacco Control Agent employed by the Louisiana Department of Revenue,hired prior to January 1,2011  \n□Wildlife Agent employed by the Enforcement Division of the LAWildlife &Fisheries Commission,hired prior to January 1,2011  \n□Judge or Court Officer,pre January 1,2011  \n□Law Clerk(Current)  □Law Clerk(Past)  \n□Judge elected after January 1,2011  \n□Legislator,Clerk,or Sergeant-at-Arms of the House;President,Secretary,or Sergeant-at-Arms of the Senate;Governor;LieutenantGovernor;or State Treasurer,hired prior to January 1,2011  \n# □Hazardous Duty Services Employee (HAZ PLAN)\n\nSECTION 3:MEMBER SIGNATURE  \nIhereby authorize the release of any information from my current/former employer which is necessary to verify this service credit.I haveread and understand this application and certify,to the best of my knowledge,all information is true and correct.I understand that anincomplete application will be returned and that it will delay the process.I further understand that there can be no duplication of servicecredit as a result of the purchase of this leave.  \nI will hold Foster and Foster Actuaries and Consultants harmless for any calculations based upon erroneous data supplied by the LouisianaState Employees'Retirement System.  \nInitial this box to have your invoice securely emailed to you.You will also receive a copy in the mail.  \nMember's Signature  \nDate  \n# SECTION 4:EMPLOYMENT CERTIFICATION (To be completed by employer certifying service to be purchased)\n\nName of Employer                        \nDaytime Area Code/Phone Number  \nJANICE  \nYou must submit Form 2-10B,Breakdovon of Contributions for Service Credit to be Purchased,for employment information during thisperiod of service.  \n  Reset Form  02-10 R012024RETAIN A COPY FOR YOUR RECORDSRETAIN A COPY FOR YOUR RECORDSLEAVEPUR Page 2 of 2","cbCaiqwezc4QECl4","https://ap.wps.com/l/cbCaiqwezc4QECl4","pdf",1087661,"English","# SECTION 2:INSTRUCTIONS\n## Eligibility options for purchasing service credit\n## Nonrefundable actuarial fee and payment methods\n## LASERS plan selection\n# SECTION 3:MEMBER SIGNATURE\n## Authorization and certification statements\n# SECTION 4:EMPLOYMENT CERTIFICATION","[{\"question\":\"What is the purpose of this LASERS application for purchase of leave?\",\"answer\":\"It requests to purchase service and salary credit for qualifying days of furlough or leave without pay under La.R.S. 11:163. The form collects member details and authorizations needed for actuarial calculations.\"},{\"question\":\"What eligibility options are available to members?\",\"answer\":\"Members can choose to purchase credit for days involuntarily furloughed due to temporary closure or a gubernatorially declared disaster/emergency, or for days placed on or voluntarily took leave without pay.\"},{\"question\":\"What fee is required and how can it be paid?\",\"answer\":\"A nonrefundable $200 fee is required for the actuarial calculation. Payment can be made by personal check, cashier’s check, certified check, or money order payable to LASERS, and returned checks incur a $15 charge.\"}]","Application for Purchase of Leave - La.R.S. 11:163 - Instructions and Certification | PDF"]